Silliman University

College of Nursing
Dumaguete City


Syllabus on Care of Patients with
Cancer of the Colon




Prepared by:
Krishaz Marie G. Co
NCM 106 B3


Submitted to:
Asst. Prof. Veveca V. Bustamante
Clinical Instructor

June 16, 2014
SILLIMAN UNIVERSITY
Vision:
A leading Christian institution committed to total human development for the well-being of society and
environment.

Mission:
Infuse into the academic learning the Christian faith anchored on the gospel of Jesus
Christ; provide an environment where Christian fellowship and relationship can be
nurtured and promoted.
Provide opportunities for growth and excellence in every dimension of the University life
in order to strengthen character, competence and faith.
Instill in all members of the University community an enlightened social consciousness and
a deep sense of justice and compassion.
Promote unity among peoples and contribute to national development
Syllabus on Care of Patients with Cancer of the Colon
Topic Description: This topic focuses mainly on the management of patients with colon cancer. It includes its related terminologies, etiology, pathophysiology,
clinical manifestations and diagnostic evaluation. The medical management as well as the nursing management with the use of the nursing process are also. In
line with this, the anatomy and physiology of the organ involved is also briefly discussed.
Central Objective: At the end of interactive discussion, the learners shall acquire knowledge, develop appropriate beginning skills and manifest desirable attitudes
and values in the care of patients with colon cancer.
Placement: 1
st
Semester, SY 2014-2015. 1
st
Rotation
Time allotment: 1 hour

Specific Objectives Contents T/A T/L Strategies Evaluation
Prayer 2
minutes

Introduction 3
minutes

Given the specific
resources, the learner
shall:
1. Define the
different
terminologies
briefly in their
own words.


I. Definition of terms
1. Polyps- ay tissue protrusion above the mucosal surface. In the
colon, polyps are protrusion in the lumen.
2. Adenocarcinoma- tumors that arise from the grandular epithelial
tissue of the colon.
3. Metastasis- Cancer spreading to other organs or tissues



5
minutes



Socialized
discussion

At the end of the 1hour
ward class, the learners
shall be able to answer
the following questions
satisfactorily:

- What is
adenocarcinoma?

2. Recall the
anatomy and
physiology of
the large

II. Anatomy and Physiology of the Large Intestine

The large intestine extends from the ileocecal valve to the anus,
approximately 5 feet long. It absorb most of the remaining water


5
minutes
Video
Presentation

Socialized
discussion

-Fill in the colon parts: a
game wherein the class
will be asked to answer
which part of the colon is
intestine.

from indigestible food residues (delivered to it in a fluid state), store
the residues temporarily, and then eliminate them from the body as
semisolid feces.
The colon has several distinct regions. As the ascending colon, it
travels up the right side of the abdominal cavity to the level of the
right kidney. Here it makes a right-angle turnthe right colic, or
hepatic, flexureand travels across the abdominal cavity as the
transverse colon. Directly anterior to the spleen, it bends acutely at
the left colic (splenic) flexure and descends down the left side of the
posterior abdominal wall as the descending colon. Inferiorly, it
enters the pelvis, where it becomes the S-shaped sigmoid colon.
The colon mucosa is simple columnar epithelium except in the anal
canal. Because most food is absorbed before reaching the large
intestine, there are no circular folds, no villi, and virtually no cells
that secrete digestive enzymes. However, its mucosa is thicker, its
abundant crypts are deeper, and there are tremendous numbers of
goblet cells in the crypts. Mucus produced by goblet cells eases the
passage of feces and protects the intestinal wall from irritating acids
and gases released by resident bacteria in the colon.



being pointed out in the
picture.

3. Discuss briefly
what is colon
cancer.


III. Definition of disease condition: Colon caner
Cancer that begins in the colon is called colon cancer, and cancer
that begins in the rectum is called rectal cancer. Cancers affecting
either of these organs also may be called colorectal cancer.
Colorectal cancer occurs when some of the cells that line the colon
or the rectum become abnormal and grow out of control. The
abnormal growing cells create a tumor, which is the cancer

5
minutes

Video
Presentation


-Explain Briefly what
colon cancer is.

Cancer of the large bowel is second only to lung cancer as a cause of
cancer death in the United States; 146,940 new cases occurred in
2004, and 56,730 deaths were due to colorectal cancer. The
incidence rate has remained relatively unchanged during the past 30
years.




4. Differentiate
the various
stages of colon
cancer


IV. Pathophysiology

1. Staging of Colon cancer
a. Stage 0- Stage 0 cancer of the colon is very early cancer. The
cancer is found only in the innermost lining of the colon.
b. Stage 1- The cancer has spread beyond the innermost lining
of the colon to the second and third layers and involves the
inside wall of the colon. The cancer has not spread to the
outer wall of the colon or outside the colon.
c. Stage 2- The tumor extends through the muscular wall of the
colon, but there is no cancer in the lymph nodes.
d. Stage 3-
The cancer has spread outside the colon to one or more
lymph nodes
e. Stage 4- The cancer has spread outside the colon to other
parts of the body, such as the liver or the lungs. The tumor
can be any size and may or may not include affected lymph
nodes



30
minutes

Presentation
of the
concept map

Socialized and
lecture
discussion




-Differentiate Stage 1
and stage 4 cancer

5. Identify at
least 3 factors
that may cause

2. Causes/Etiology and Risk Factors

a. Diet

-Give at least three
causes of colon cancer
and an example under
colon cancer.

i. Animal Fats- ingestion of animal fats such as are
found in red meats and processed meat leads to an
increased proportion of anaerobes in the gut
microflora, resulting in the conversion of normal bile
acids into carcinogens.
ii. Insulin Resistance- Diets high in animal (but not
vegetable) fats are also associated with high serum
cholesterol, which is also associated with enhanced
risk for the development of colorectal adenomas and
carcinomas.

b. Hereditary Factors and syndromes
i. Polyposis Coli- polyposis coli (familial polyposis of the
colon) is a rare condition characterized by the
appearance of thousands of adenomatous polyps
throughout the large bowel.
ii. Hereditary Nonpolyposis Colon Cancer- also known as
Lynch syndrome, is another autosomal dominant trait. It
is characterized by the presence of three or more
relatives with histologically documented colorectal
cancer, one of whom is a first-degree relative of the
other two; one or more cases of colorectal cancer
diagnosed before age 50 in the family; and colorectal
cancer involving at least two generations. In contrast to
polyposis coli, HNPCC is associated with an unusually
high frequency of cancer arising in the proximal large
bowel.

c. Inflammatory Bowel Disease
i. Ulcerative Colitis- similar to Crohns disease. Crohns
disease, however, can occur anywhere in the
this cause.
gastrointestinal system, whereas ulcerative colitis occurs
in the large colon and rectum. Multiple ulcerations and
diffuse inflammation occurs in the superficial mucosa and
submucosa of the colon. The lesions spread throughout
the large intestine and usually involve the rectum. The
patient with ulcerative colitis has increased risk of
developing colorectal cancer.
ii. Crohns Disease- also known as regional enteritis or
granulomatous enteritis, is an inflammatory bowel
disease (IBD) that can involve any part of the intestine
but most commonlythe terminal portion of ileum. The
inflammation extends through the intestinal mucosa,
which leads to the formation of abscesses, fistulas, and
fissures. As the disease progresses, obstruction occurs
because the intestinal lumen narrows with inflamed
mucosa and scar tissue.

d. Lifestyle Factors- You may be at increased risk for developing
colorectal cancer if you drink alcohol, smoke, don't get
enough exercise, and if you are overweight. Tobacco Use
Cigarette smoking is linked to the development of colorectal
adenomas, particularly after 35 years of tobacco use. No
biologic explanation for this association has yet been
proposed.

e. Age and Gender- the disease is most common in people over
the age of 50, and the chance of getting colorectal cancer
increases with each decade. The risk overall is equal, but
women have a higher risk for colon cancer, while men are
more likely to develop rectal cancer.


f. Other High Risk Conditions
i. Streptococcus bovis Bacteremia- for unknownreasons,
individuals who develop endocarditis or septicemia from
this fecal bacteria have a high incidence of occult
colorectal tumors and, possibly, upper gastrointestinal
cancers as well. Endoscopic or radiographic screening
appears advisable.
i. Ureterosigmoidostomy- Colon cancer develops in 5 to
10% of people 15 to 30 years after
ureterosigmoidostomy to correct congenital extrophy 77
Gastrointestinal Tract Cancer 529 of the bladder.
Neoplasms characteristically are found at a site distal to
the ureteral implant where colonic mucosa is chronically
exposed to both urine and feces.


6. State the
possible
clinical
manifestations
of colon cancer
in accordance
to its location.


3. Clinical Manifestations
a. Location
i. Right sided lesions- commonly ulcerate, leading to
chronic, insidious blood loss without a change in the
appearance of the stool. Gross blood not usually
detected.
ii. Left sided lesions- gross blood is common but not
massive. associated with obstruction (ie, abdominal
pain and cramping, narrowing stools, constipation,
and distention), as well as bright red blood in the
stool.
iii. Cecum and ascending colon- present with symptoms
such as fatigue, palpitations, and even angina pectoris

- What are the possible
effects of
right sided lesions?

- How does cancer in the
descending and
transverse colon affect
the body?

- What signs could alert
you as a nurse that the
patient has a blockage in
the colon?
and are found to have a hypochromic, microcytic
anemia indicative of iron deficiency.
iv. Transverse and descending colon- Since stool
becomes more concentrated as it passes into the
transverse and descending colon, tumors arising
there tend to impede the passage of stool, resulting
in the development of abdominal cramping,
occasional obstruction, and even perforation.
Radiographs of the abdomen often reveal
characteristic annular, constricting lesions
(applecore or napkin-ring)
v. Rectosigmoid- often associated with hematochezia,
tenesmus, and narrowing of the caliber of stool;
anemia is an infrequent finding.

b. Changes in bowel habit
i. Blood in stools- positive result for FOBT. Microscopic
amounts of blood that are not noticeably visible.
Patient may have mahogany (dark)- colored or bright
red stool
ii. Anemia, anorexia, weight loss, fatigue- Anemia due
to bleeding. Fatigue and weakness due to anemia and
decrease in hemoglobin and hematocrit levels.
Anemia due to bleeding. Fatigue and weakness due
to anemia and decrease in hemoglobin and
hematocrit levels.



7. Explain in their
own words the

4. Complications
a. Intestinal Obstruction- Intestinal obstruction or blockage

- In your own terms
based on the concepts
possible
complications
of colon cancer

in the colon occurs when waste products (feces) are
unable to move through the intestine. Causes include
mechanical blockage such as scar tissue from surgery or
radiation, cancer progression (metastasis), or an ileus
where no mechanical blockage exists but the intestine is
unable to contract and relax.
b. Recurrence- Recurrence, or the return of the cancer after
a period of time, happens when surgery does not remove
the primary tumor completely or hidden cancer cells
remain. Local (site of the original tumor), regional (in the
lymph nodes near the primary tumor) or distal (in
another part of the body) recurrence may occur. For
example, the patient seems to be cancer free for a year
and then the cancer returns. Progression of the disease is
said to occur when the tumor grows during treatment
(usually in the first few months), which indicates an
aggressive type of tumor.
c. Metastasis- ancer cells that break away from the primary
tumor and travel in the blood stream or lymph system to
other parts of the body cause metastases. These new
sites of disease are still colon cancer, even when they are
in other organs of the body. Metastasis in colon cancer
usually is seen in the liver and lungs but may occur in
other sites.
d. Development of a Second Primary Cancer - When a
second primary colon cancer develops, it is said to be
metachronous colon cancer. Metachronous colon cancer
is described as a cancer that develops six or more months
after the primary tumor and is often in another site.
Because colon cancer often develops from polyps (or
growths) in the colon, a second primary cancer may
you have learned, what
is cold be the possible
complications of colon
cancer?
occur.

8. Correctly
enumerate the
possible
outcomes of
the laboratory
and diagnostic
findings of a
colon cancer
patient.


5. Laboratory and Diagnostic Findings
a. Stool Tests- When doctors test for fecal occult blood
they are testing for the presence of microscopic or
invisible blood in the stool, or feces. Fecal occult blood
can be a sign of a problem in your digestive system,
such as a growth, or polyp, or cancer in the colon or
rectum. If microscopic blood is detected, it is important
for your doctor to determine the source of bleeding to
properly diagnose and treat the problem.
Because certain foods can alter the test results, a
special diet is often recommended for 48 to 72 hours
before the test.
The following foods should not be eaten 48 to 72 hours
before taking the test:
Beets, Broccoli, Cantaloupe, Carrots,
Cauliflower, Cucumbers, Grapefruit,
Horseradish, Mushrooms, Radishes, Red meat
(especially meat that is cooked rare), Turnips,
Vitamin C-enriched foods or beverages.

Your doctor will go over your medicines with you
before the test, since you may need to stop taking
certain medicines 48 hours before the test such as
aspirin and vitamin c.

b. Colonoscopy- usually used to evaluate symptoms like
abdominal pain, rectal bleeding, or changes in bowel
habits. They are also used to screen for colorectal

-What could be the FOBT
findings of a patient with
colon cancer?

-During CT Scan what are
the common areas that
colon cancer could
metastasize?
cancer.
You may be asked to limit or eliminate solid foods for a
few days before the test. You may also be asked to take
laxatives by mouth. Along with the dietary changes,
your bowel must be further cleansed in order for
colonoscopy to be successful. You will receive two
enemas before the procedure because the rectum and
lower intestine must be empty so that the intestinal
walls can be seen.
During the colonoscopy, if the doctor sees something
that may be abnormal, small amounts of tissue can be
removed for analysis (called a biopsy), and abnormal
growths, or polyps, can be identified and removed. In
many cases, colonoscopy allows accurate diagnosis and
treatment without the need for a major operation.

c. CT Scan- These tests use technologies that visualize
your body organs and present them like a picture.
Imaging tests are also used to determine how far the
cancer has spread or how well it is responding, or has
responded, to treatment.

d. Genetic Testing- may be offered to high-risk families to
determine an individual's risk for developing certain
genetic forms of colorectal cancer.

9. Correctly
relate the
mechanism of
action of the

6. Medical and Surgical Management
a. Surgery- Surgery may be used to remove cancer from
the colon or rectum. Or it may be done to remove
cancer that has spread to other organs in the body. The

-What is the mechanism
of action of Avastatin in
our body?

different
medical and
surgical
management
for colon
cancer

type of surgery chosen depends upon the stage of the
cancer.
Stage 0 colon cancer may be treated by removing the
cancer cells. This is done using colonoscopy. For stages
I, II, and III cancer, more extensive surgery is needed to
remove the part of the colon that is cancerous. This
surgery is called colon resection.

- Bowel resection. The surgeon cuts out the cancer in
the colon or rectum as well as the parts of the colon or
rectum that are next to it. Then the two healthy ends of
the colon or rectum are sewn back together.
-Liver resection. The surgeon cuts out cancer that has
spread to the liver, as well as parts of the liver that are
next to the cancer. If the cancer in your liver is too large
to remove with surgery, you may be given
chemotherapy. It can shrink the tumor so it can be
removed.

-Lung, adrenal, or ovarian resection, depending on
where the cancer has spread and whether you are a
good candidate for this surgery.

b. Chemotherapy: a term used by doctors to refer to
drugs that can kill cancer cells. Chemotherapy drugs
can be given in a variety of ways, including
intravenously by injection, intravenously with a pump,
or even in pill form taken by mouth. Each drug works
against a specific cancer, and each drug has specific
doses and schedules for taking it. Chemotherapy can be
given in a variety of situations
-What type of
chemotherapy is done
after a surgery?

i. Palliative- used when colorectal cancer is advanced
and has already spread to different parts of the body.
In this situation, surgery cannot eliminate the cancer,
so your best bet is to be treated with chemotherapy,
which may shrink tumors, alleviate symptoms, and
prolong life.
ii. Adjuvant- given after the cancer is surgically
removed. The surgery may not eliminate all the
cancer cells, so the adjuvant chemotherapy
treatment is used to kill any that may have been
missed, such as cells that may have metastasized or
spread to the liver.
5-fluorouracil (5-FU), 5-FU plus levamisole (an
antihelmintic agent that appears to modulate the
cellular immune response); or 5-FU with leucovorin (a
folic acid derivative) may be used.
iii. Deoadjuvant- chemotherapy given before surgery.
Chemotherapy drugs may be given prior to surgery in
order to shrink the tumor so that the surgeon can
completely remove it with fewer complications.
Chemotherapy is also given with radiation, as it
makes the radiation more effective.

c. Radiation- Radiation therapy treats cancer by using
high energy to kill tumor cells. The goal is to kill or
damage cancer cells without hurting healthy cells.
The most common early side effects from radiation
therapy are fatigue and skin problems. Other early side
effects such as hair loss and nausea are typically
specific to the site being treated.

d. Biological Therapy: Immunotherapy, also called
biological therapy, is a type of treatment that uses the
body's own immune system to fight cancer. The
therapy mainly consists of stimulating the immune
system to help it do its job more effectively.
Immunotherapy is a fairly new way to fight colorectal
cancer. Many of these treatments are still in clinical
trials.

i. Biological Response Modifiers- These substances do
not directly destroy the cancer, but they are able to
trigger the immune system to indirectly affect
tumors. Biological response modifiers include
cytokines (chemicals produced by cells to instruct
other cells) such as interferons and interleukins. This
strategy involves giving larger amounts of these
substances by injection or infusion in the hope of
stimulating the cells of the immune system to act
more effectively.

ii. Colony Stimulating Factors- These are substances
that stimulate the production of bone marrow cells,
which include both red and white blood cells and
platelets. Often, other cancer treatments cause
decreases in these cells. Thus, colony-stimulating
factors do not directly affect tumors, but they can
help support the immune system during cancer
treatment.


iii. Tumor Vaccines- Researchers are developing vaccines
that may encourage the immune system to better
recognize cancer cells. These would, in theory, work
in a similar way as vaccines for measles, mumps, and
other infections. The difference in cancer treatment
is that vaccines are used after someone has cancer,
and not to prevent the disease. The vaccines would
be given to prevent the cancer from returning or to
get the body to reject tumor lumps. This is much
more difficult than preventing a viral infection. The
use of tumor vaccines continues to be studied in
clinical trials.

iv. Monoclonal Antibodies: These are substances
produced in the lab that can locate and bind to
cancer cells wherever they are in the body. These
antibodies can be used to see where the tumor is in
the body (detection of cancer), or as therapy to
deliver drugs, toxins, or radioactive material directly
to a tumor.
a) Erbitux (cetuximab)- A monoclonal antibody
which works by binding to a protein receptor
to slow cell growth.
b) Avastatin (bevacizumab)- This drug works by
shutting down a process called angiogenesis --
the process whereby tumors grow new blood
vessels to help them receive the nutrients
needed to survive.
c) Vectibix (panitumumab)- is similar to Erbitux
for treating colorectal cancer that has spread
and progressed after treatment with other
chemotherapy.

10. Create a
nursing
diagnosis with
3 nursing
interventions
for a colon
cancer patient


7. Nursing Management/ Intervention
Assessment
The nurse completes a health history to obtain information about
fatigue, abdominal or rectal pain (eg, location, frequency, duration,
association with eating or defecation), past and present elimination
patterns, and characteristics of stool (eg, color, odor,consistency,
presence of blood or mucus). Additional information includes a history of
IBD or colorectal polyps, a family history of colorectal disease, and
current medication therapy. The nurse identifies dietary habits, including
fat and fiber intake, as well as amounts of alcohol consumed. The nurse
describes and documents a history of weight loss.
Assessment includes auscultating the abdomen for bowel sounds and
palpating the abdomen for areas of tenderness, distention, and solid
masses. Stool specimens are inspected for character and presence of
blood.

Nursing diagnosis
Based on the assessment data, may include acute pain related to tissue
compression from the tumor, anxiety related to diagnosis of cancer,
imbalanced nutrition: less than body requirements related to nausea and
anorexia, and deficient knowledge related to surgery and postoperative
care.

Planning
Goals include relief from pain, alleviation of anxiety, achievement of
optimum nutritional status, and understanding of self-care following
surgery.

-Identify one priority
nursing diagnosis for a
patient with colon cancer

-Give at least 3
interventions that is of
top priority in the care of
patients with colon
cancer.

Implementation
Set aside time to allow the patient who so desires to talk, cry, or ask
questions about the diagnosis and planned surgery. Postoperatively,
administer analgesics as prescribed. Provide a quiet, relaxing atmosphere
to help alleviate anxiety, and limit visitors and telephone calls if the
patient prefers. Postoperative care includes monitoring vital signs, the
stoma, and the return of bowel sounds and flatus, indicating peristalsis
has resumed, and ambulation, coughing and deep breathing, and
dressing changes as ordered. Dressings are observed for drainage. Large
amounts of drainage or bleeding are reported. If a drain is inserted, often
in the perineal wound, moderate amounts of serosanguineous (light
pink) drainage are expected. Frequent dressing reinforcements or
changes are needed to keep the area dry.
Total parenteral nutrition may be necessary to provide depleted
vitamins, minerals, and nutrients if the patient has been anorexic for any
length of time or has had a significant weight loss. After bowel sounds
return, provide the patient with a high-protein, high-calorie diet, as
ordered, that is low in residue to decrease excessive peristalsis and
minimize cramping. If the patient is anemic, blood transfusions may be
necessary.

Evaluation
Expected outcomes are that the patient verbalizes less anxiety and
control of pain, attains an optimum level of nutrition, and verbalizes
understanding of the disease and treatment. If the patient has a
colostomy, the stoma is observed by the patient and a return
demonstration of the appliance change should be done before discharge.

Evaluation 10
minutes

Open forum

References
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Smeltzer,S,et.al.(2008) Brunner & Suddarths Textbook of Medical-Surgical Nursing,11th Ed (Vol1).Ph: Lippincott Williams & Wilkins
Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes, 7th ed. Philippines: Elsevier Pte. Ltd.
Kasper, D. & Harrison T. (2005). Principles of Internal Medicine 16th Ed (Vol1) New York: McGraw- Hill, Medical Pub, Division
Poth, C. (2011). Essentials of Pathophysiology: Concepts of Altered Health States 3rd Ed Philadelphia, Pa: Wolters Kluwer/ Lippincott Williams &
Wilkins
Huether, S., McCane, K (2008) Understanding Pathophysiology ,4th Ed. St Louis Mo: Mosby Elsevier
Williams, L & Hopper, P (2010) Understanding Medical-Surgical Nursing, 4th Edition. F.A. Davis Company
http://www.livestrong.com/article/91661-complications-colon-cancer/
http://www.webmd.com/colorectal-cancer/default.htm?names-dropdown=
http://www.youtube.com/watch?v=DABeD_X-jm4